Screening for depression and risk of suicide in patients with arthritis: Comment on the article by Tektonidou et al


Screening for Depression and Risk of Suicide in Patients with Arthritis: Comment on the Article by Tektonidou et al

To the Editor:

Tektonidou and colleagues (1) reported that 5.6% of adults with self-reported arthritis from the US National Health and Nutrition Examination Survey responded something other than “not at all” on item 9 of the 9-item Patient Health Questionnaire (PHQ-9). Item 9 of the PHQ-9 asks, “Over the last two weeks, how often have you been bothered by the following problem: thoughts that you would be better off dead, or of hurting yourself in some way?” The authors interpreted this item as an indicator of suicidal ideation. They concluded that the PHQ-9 could be used to screen patients with arthritis for depression and that patients with suicidal thoughts, presumably based on their PHQ-9 response, “should receive close monitoring and early intervention” (1).

Recommendations to screen for any medical condition that are not based on positive results from high-quality randomized controlled trials (RCTs) risk consuming scarce health care resources and harming some patients without evidence of benefit. As described in a recent analysis, there are many examples of depression-screening RCTs in which patients who screened positive for depression were referred for mental health care services, as recommended by Tektonidou et al. However, all of these trials have been negative, and none have found that screening reduced the number of patients diagnosed with depression or improved depressive symptoms (2). The United States Preventive Services Task Force (USPSTF) recommends depression screening in primary care settings when integrated systems for coordinated depression assessment, management, and followup are available (3), but no trial has demonstrated that this would produce better results than standard care (2), and these integrated depression management systems are not typically present in rheumatology settings.

In its most recent review of screening for suicide risk in primary care, the USPSTF (4) did not identify any studies that reported that screening for suicide risk reduced suicide attempts or mortality. Beyond screening, if one were to use questionnaires or single items to assess suicide risk for research or clinical purposes, item 9 of the PHQ-9 would not be an ideal choice. Item 9 queries patients about both passive “thoughts of being better off dead” and active “thoughts of hurting oneself.” In studies of medical patients, many patients endorsed item 9. However, even in clinical trials of patients with depression in medical settings, most patients who endorsed item 9 were agreeing with the first part only, passive thoughts about “being better off dead” (5, 6).

Depression and suicide are important public health problems, and there is an urgent need to improve the quality of mental health services for patients in medical settings, including patients with rheumatoid arthritis. It should not be simply assumed, however, that screening for depression or suicide risk would benefit patients, particularly when existing evidence suggests otherwise and given the potential of harm to some patients, as well as the certainty of high costs and consumption of scarce health care resources (2).


Mr. Razykov's work was supported by a McGill University Faculty of Medicine Alexander McFee Fellowship and by a Canadian Scleroderma Research Group Studentship (Canadian Institutes of Health Research Strategic Training Initiative in Health Research Grant). Ms Levis's work was supported by a Canadian Institutes of Health Research Undergraduate Studentship. Dr. Thombs's work was supported by a New Investigator Award from the Canadian Institutes of Health Research and an Établissement de Jeunes Chercheurs award from the Fonds de la Recherche en Santé Québec.

Ilya Razykov BA*, Brooke Levis BSc*, Brett D. Thombs PhD*, * McGill University and Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada.